Abstract
Perioperative risk for patients undergoing liver transplantation is influenced by the severity of their liver disease as well as by extrahepatic complications including frailty, sarcopenia, poor exercise tolerance and cardiorespiratory pathology. Safe intraoperative care depends upon an understanding of the surgical procedure and an appreciation of the physiological changes which occur during the anhepatic stage and at reperfusion of the donor graft. Cardiovascular and respiratory dysfunction, acute kidney injury, and severe bleeding due to the surgery, portal hypertension and coagulopathy are common in the perioperative period. Robust strategies for detecting and correcting coagulopathy, as well as meticulous attention to fluid balance and electrolytes, are essential. Live donors are extensively screened and in good general health. Their intraoperative management is similar to that of patients undergoing liver resection.
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Self Study
Self Study
1.1 Questions
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1.
Which of the following statements is true?
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(a)
Candidates are prioritised for liver transplant based primarily on an assessment of their frailty.
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(b)
Any degree of portopulmonary hypertension is generally considered a contraindication to liver transplantation.
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(c)
At the time of transplant, patients may be at increased risk of haemorrhage, thrombosis, or both.
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(d)
Preoperative correction of laboratory coagulation tests is important to reduce the risk of intraoperative haemorrhage.
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(a)
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2.
Which of the following statements is true?
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(a)
European Society of Anaesthesiology guidelines recommend against the use of point-of-care viscoelastic testing in liver transplantation.
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(b)
Intraoperative cardiac arrest during orthotopic liver transplantation is very rare.
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(c)
The severity of bleeding during surgery does not predict transplant outcomes.
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(d)
Living donation may allow candidates to undergo transplantation who would not qualify to receive a deceased donor liver.
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(a)
1.2 Answers
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1.
Which of the following statements is true?
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(a)
Prioritisation is usually based on liver disease severity, and the most commonly used measure is the MELD score.
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(b)
Mild portopulmonary hypertension increases perioperative risk only slightly and is not generally considered a contraindication to transplant. Severe portopulmonary hypertension is generally considered a contraindication.
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(c)
CORRECT ANSWER. The cell-based model of coagulation explains that while coagulation in chronic liver disease is ‘rebalanced’, there is an increased vulnerability to stressors that may increase the tendency to thrombosis, haemorrhage, or both.
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(d)
Laboratory coagulation tests are poor predictors of surgical bleeding and are not normally corrected preoperatively.
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(a)
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2.
Which of the following statements is true?
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(a)
ESA guidelines support the use of an algorithmic approach with predefined viscoelastic triggers for the treatment of perioperative bleeding. They also state that there is some evidence to suggest that viscoelastic testing reduces bleeding during liver transplantation.
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(b)
The rate of cardiac arrest within minutes of donor organ reperfusion is around 3% in some series.
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(c)
Massive haemorrhage during liver transplant surgery predicts worse graft and patient survival.
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(d)
CORRECT ANSWER. Candidates with hepatocellular carcinoma falling outside of standard transplantation criteria, and those with liver disease of insufficient severity to prioritise them for deceased donor transplant, may undergo living donor transplant.
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(a)
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Milliken, D.M., Davidson, B.R., Spiro, M.D. (2020). Anaesthesia for Liver Transplantation. In: Radu-Ionita, F., Pyrsopoulos, N., Jinga, M., Tintoiu, I., Sun, Z., Bontas, E. (eds) Liver Diseases. Springer, Cham. https://doi.org/10.1007/978-3-030-24432-3_70
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